Revenue Cycle Insider

Question: I have a report for a 42-year-old patient who presented with left ankle pain. The radiologist captured three ankle X-ray views and noted the presence of a foreign body in the ankle. The medical history section revealed that the patient had left ankle surgery five years ago, during which the provider inserted pins into the fibula and the lateral malleolus. The radiologist documented that the foreign body appears to be one of the fibula pins.

What codes should I assign for the encounter?

Alaska Subscriber

Answer: Use 73610 (Radiologic examination, ankle; complete, minimum of 3 views) to report the three-view ankle X-rays. Make sure the documentation includes the types of views and that the images are permanently recorded in the record, too.

Next, you’ll turn your attention to the diagnosis codes. Since the issue arose from a pin becoming dislodged, you’ll need to examine codes related to complications of an internal fixation device. In the Alphabetic Index search for Complication(s) (from) (of) > fixation device, internal > displacement > fibula, which refers you to T84.12- (Displacement of internal fixation device of bones of limb). Turn to the Tabular List to verify the code selection.

Code T84.127- (Displacement of internal fixation device of bone of left lower leg) requires a 7^th character to complete the code. The displaced pin is causing the current issue, and the patient is seeking active treatment for the condition. This means you’ll use “A” as the 7^th character. The complete code is T84.127A (Displacement of internal fixation device of bone of left lower leg, initial encounter).

Mike Shaughnessy, BA, CPC, Production Editor, AAPC